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HomeMy WebLinkAbout1794A (10) WORKERS'COMPENSA710NDECLARATION 78A663 ,o�e, qppLICATION FOR ELECTRICAL PERMIT �—� {� I hereby affirm that I have a certificate of Consent to 5elf Insure, cE-Bo6G or a certificate ot Nbrkers Canpensatbn Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AN�SAFETY �� . copy thereof Sec.360D,Lah.C.) ^' PoIiCy N0�COmpa�NDU�Z/M . _ FOR APPLICANT TO fllL IN JOD h�- '�A"/T EACH NO. FEE AODRESS ? ❑ .Certif'�ed copy is hereby fumished. . ���• New Residential Bldgs.&PopV���./ � _ g LOCALIT�2 / � ��Certified copy Is filed with the counry buildirg inspection 1&2-Family,Sq.FL oi y — , MUItI•f3mily Sq.Ff. NEAREST /�J rtment�� i/) � �� CROss 57. �!/ h�-1 Residential Swimming Pools - - - �-� pwNEq Oq Date V Applicant �l���'� . .. FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS� . Outlets Ree_Light_Sw,— �� MA� � � COMPENSATION INSURANCE - � � - � � �� ADORES �• . (This sectbn naed not be eompietetl H the work Involved by the Total No. A'ddk ooal� � -� � � CITY � � Q� Tel.No 6 - � permit Is lor one hundrad dollera(4100)or less.) � �aM cnECK I certiry thet in the performante of the-vrork for whiCh this permit ApPLICAM - �� is issued,1 shall not employ arry person in any manner so as to � become subject to the Workers Compensation Laws._ L'ghting Flxtures First 20 - ADDRESS — Additional' Tet.No. ' � - ' � � Total No. CITY - - Date APP����t � Fxed Appliances Not Over 1 HP, pEaMi7 /� NCTiCE�TO APPLICANT: If, after making�,this Certifica[e af ppp��p� . Exrmption,you should become subject M the Workers'Compensation . .. Range_Hea[er_D.W. __ _ - provisims ot the Labor Code,you must forthwiih comoly with such Oven_Dryer_ W.M._ ADDRESS .v x���� � �.provisions or this permit shall be deemed mwked. ,, Top-_FAU _W.H._ ��- - � GT v ��'J� Tel.No �lj y�j LICENSED COIJTF2ACTORS DECLARA710N Hood_ Fan _Other_ LICENSE R I hereby atfirm ihat I am licensed uMer provisions oi Chapter 9 � Disp. �—Room Air Cond. _ � � Cias �� (COI1tm2nCiflg With SCCfiOn 7000)of�rvi510f1 3 01 thB BUS�f1855 and REG.NUMBER PfOfeSSI0n3 COd@,and my IiCense IS In full(OfCC 311d BffCCL . PoWef App2/atuS&Ldfg@ ApP��anGeS . _ DISTRICT NO. ///��� PROCESSEO BY a Size 8 Type HP,KW,KVA,or KVAR � � � " `��U� U ,r� _ License Number �/� Lic.CIa59 �� - � � Up to t inCl. - - FINAL 9 � ��7 Over 1 to 10 InCI. �A� / ��/ VALIDATON � Contractor C���x-� Date Over 10 to 50 Ind. FINAL U ❑. I am exempt under Sec. � Over 50 fo 100 Inc.... BY //��� . _. - a 8.8P.C.tor this reason Over 100 � - �� Services;Sdibd.,MCC 8 PSrieltioards" � - Z " - �ate: 0-200 Amp.Under 600 V , �1 7 9•4 A Signalure � 201-1000 Am0.�Uridei 600 V�� �� � , o e� Over 1000 Amp.or Over 600 V � Ezemption tor Reg.MaiM.Elect. - � �� - � - I � 1 1 5.8 6 � � - SINGLE FAMILY - � - Temp.Power Pole&Appurtenances . . . � HOME OWNER-BUILDER OECLARATION Sign with One Branch Circuit • ° � � �.r 6�' I hereby alFirm that I am exempt from the Contractors License Law Additional Sgn Branch Circuits - � � - � for the tollowing reason(Section 7031.5,Business and Prolessions o 9.2 2—8 8 Code�: �- Misa Conduils 8 Conductors�-� � � ❑ I,as owner of the property,will do the vrak and the structure . is not intended or offered fa sale(Section 7044,Business Other(See Complete Fee Schedule)_ , and Protessions Code). � CONSTRt1CTION LENDING AGENCY � � I here6y affirm that there is a construction tendirg agency for the � performance oF the work for which this permR is issued(Sec.3097, pERMR FEE (Sub-Totap - Civ.C.1. _ ' PLAN CHECKING FEE � � - � Lender's Name � PERMR ISSUMG FEE � � � - � - � Lender's Address //s Gq � � I certify that I have read this application antl state that the above TOTAL FEE . .. . . .. . p f7 - .- � � - . � informatlon is corred.I agree to Comply with a�l County ordinances - 1 and State laws regulating Electr�al wiring,and here6y authorize . . . _ _. . . _ ._. . _ _ . . � - - f representatives of ihis County to enter upon the above-mentioned � y for inspeetion purposes. �-SEE REVERSE FOR EXPLANATORY LANGUAGE � � � _ . <i ����� ' Signature of Permit[ee Date • � ,'.,_ , . , ,� ,: . ._ -----� � ' ; � , ' ;' � . � _ � I , �� � . , ; . ,�_ ;.% / ' " . ,•'. � I _ � � ,: ; t . . . _ � - � _ _ ; j i i '' �, :_ ; ; � �;- . ; .. _r ,� - - i .� E . . � �,Z T C O' ?t. �.5� �37 C --1 � . �� ..t r i . � , [fi � —I f�n C �Z O R1 'V , . . �. < � m c) 2 � .D : �` �/ - � O C u'. 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